PREVENTION OF NOSOCOMIAL PNEUMONIA

Nosocomial PneumoniaNosocomial Pneumonia Second most common nosocomial infection in US

◦ 15% of all hospital-associated infections

◦ incidence range from 4.2 to 7.7/1000 discharges

Associated with substantial morbidity and mortality: VAP mortality can reach 60% in ICU

Risk Factors for nosocomial pneumonia ◦ extremes of age

◦ severe underlying disease

◦ immunosuppression

◦ depressed sensorium

◦ cardiopulmonary disease

◦ thoracic-abdominal surgery

◦ mechanically assisted ventilation

Nosocomial InfectionsNosocomial Infections Lower Respiratory Infections Lower Respiratory Infections Modifiable Risk Factors Modifiable Risk Factors

Strong evidence◦Semi-recumbent◦Noninvasive

ventilation◦Continuous

lateral rotation◦Subglottic

suctioning

Some evidence◦Avoid over

sedation◦Avoid paralytics◦Closed suctioning◦Orotracheal

intubation◦Maintain adequate

cuff pressures◦Avoid H2

antagonists

Nosocomial Pneumonia - Nosocomial Pneumonia - DiagnosisDiagnosis

In intubated patients, do not culture unless you suspect pneumonia, you will grow something

Do a quantitative culture when possible - suctioned or bronchial alveolar lavage (BAL), they are more accurate; ◦ > 10K suggests infection

Do a gram stain with each culture looking for WBCs

Major Prevention MeasuresMajor Prevention MeasuresStaff Education - Category 1BSurveillance - Category 1B

◦Use standardized definitions◦ICU and High risk patients◦ Identify causative organisms◦Express rates

Number of infections/1000 vent days or # of infected patients/100 ICU days

Do not routinely perform surveillance cultures on patients or equipment - Category IB

Recommendations - Category IRecommendations - Category I

Do not change routinely, on basis of duration or use, the ventilator circuit that is in use on an individual patient. Rather change the circuit when it is visibly soiled or mechanically malfunctioning.

Periodically drain and discard any condensate that collect in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward patient. Decontaminate hands ….after performing procedure or handling fluids.

Category ICategory IUse only sterile, filtered or

pasteurized fluid for nebulization and dispense into the nebulizer aseptically.

Decontaminate hands with soap and water or waterless antiseptic agent after contact…….

Change gloves and decontaminate hands…...

Major Prevention MeasuresMajor Prevention MeasuresInterruption of Transmission of

Microorganisms◦ Sterilization and disinfection of equipment

General Measures Mechanical Ventilators, Breathing Circuits,

Humidifiers, Heat and Moisture Exchange, Nebulizers

Wall Humidifiers Small volume medication nebulizers Mist Tents Other devices Anesthesia Machines and system Pulmonary Function testing Equipment Room air humidifiers and faucet aerators

Supine Body Position & VAPSupine Body Position & VAP

RCT: 39 semirecumbent vs 47 supine pts

Risk Factors◦Supine Position OR = 6.8 (1.7-26.7)◦Enteral Nutrition OR = 5.7 (1.5-22.8)◦MV>7 days OR = 10.9 (3.0-40.4)

VAP= 50% in supine patients with enteral feeding

Major Prevention MeasuresMajor Prevention MeasuresInterruption of Person to Person

Transmission of Bacteria◦SP◦Care of patients with trachs◦Suctioning

Modifying Host Risks◦Vaccines -pneumococcal vaccine- Category IA◦Prevention of Aspiration Precautions◦Other prohylactic procedures for Pneumonia

Major Prevention MeasuresMajor Prevention Measures

Prevention of Healthcare associated Disease◦Legionairre’s Disease◦Pulmonary Aspergillosis◦RSV, Parainfluenza, and Adenovirus

◦Influenza

Smoking cessationSmoking cessation

Decrease risk of VAP if stop smoking prior to surgery

Oral HygieneOral Hygiene

Performance MeasuresPerformance MeasuresHow do you measure compliance in your facility?

Performance Measures for Performance Measures for Pneumonia PreventionPneumonia Prevention

Measure VAP rates using established benchmarks and standardized definitions◦(e.g. CDC NNIS definitions and rates)

Provide feedback to staff and leadership about facility/unit-specific VAP rates

Aggressive education on evidence-based prevention measures to reduce pneumonia

Involve process owners: ICU nurses, MDs, Respiratory Therapy staff!

Influenza Performance Influenza Performance MonitorsMonitors2. Establish a influenza vaccination program,,

monitoring the % of eligible patients in acute-care settings or patients or residents in long-term–care settings who receive the vaccine.

3. Before and during the influenza season, monitor and record # of eligible health-care personnel who receive influenza vaccine and determine the desired unit/facility-specific vaccination rates (recommended by ACIP.)

Performance Monitors for Performance Monitors for RSVRSV

4. Monitor the (#) number of cases of health-care–associated RSV infections by geographic location within the facility.

Give prompt feedback to appropriate staff members to improve adherence to recommended infection control precautions.

Performance MonitorsPerformance Monitorsfor Construction-Related for Construction-Related AspergillosisAspergillosis6. During construction or

renovation activities in the facility, monitor personnel adherence to infection-control measures (e.g., use of barriers, maintenance of negative room pressure) that are aimed at minimizing dust dispersion patients in patient-care areas. Review all cases of healthcare–associated aspergillosis to determine the presence of remediable environmental risks.

7. Periodically monitor the frequency of diagnostic testing for pertussis and the time interval between suspicion of the infection and initiation of isolation precautions for patients in whom pertussis is suspected.

Performance Monitors for Pertussis

Preventing Other Preventing Other Device-Related InfectionsDevice-Related Infections

Other Implantable Other Implantable DevicesDevices

Heart Valves ◦ 1-9% of patients develop infections

Vascular Grafts◦ NNIS CBGB Graft infection rate = 1.18-10.23%

CNS Devices- NNIS Ventriculostomy rates◦ range from 4.22 to 5.39 % depending on procedure

and risk index category Defibrillators & Pacemakers Joints pooled mean rates range for hips and knees

=0.87 to 3.70 % depending on procedure and risk index category

Basic Principles & FactsBasic Principles & Facts

Same Strategies as preventing SSIs

Settings◦OR◦Other areas

Monitor Process and OutcomesEducation

Performance Improvement by Performance Improvement by Infection Risk Reduction Infection Risk Reduction Strategies for Invasive Strategies for Invasive Procedures and Insertion of Procedures and Insertion of Devices in Special Settings Devices in Special Settings

Cardiac Cath Lab & RadiologyCardiac Cath Lab & Radiology

Source: Loretta Fauerbach, Shands Hosp. U of FL

Initial Procedure Specific Infection Initial Procedure Specific Infection Rate by AreaRate by Area

0 1 2 3

1998

RadiologyCardiac Cath

% ( infection rate)

Year

Source: L. Fauerbach, Shands Hosp. U of FL

Performance Improvement Performance Improvement TeamTeam

Infection Control PractitionersHospital EpidemiologistOR EducatorCardiac Cath Lab StaffSpecial Procedures Radiology StaffMedical Directors for both areasCSS managerSurgeon

Action PlanAction PlanObservational Studies in Radiology

and Cardiac Cath LabContinue infection surveillance

activitiesFormulate recommendations

specific for each unit◦Literature review

Educate physicians and staffMeasure impact through

surveillance and provide feedback

Surveillance Surveillance Performed by the ICPs

◦Review of Lab reports◦Reports from unit/medical staff◦Chart review

Procedure specific (SSI) ratesBacteremias

◦ (calculated per 100 patients since device days were not available)

Trending and Activities Trending and Activities CommunicationCommunication

Infection Prevention and Control Committee

Specific Areas

Medical Chiefs/ Services

Operation Committee of Medical Staff

Dept. QA

PS/QEC

Quality Committee of Board

Results of Observational StudiesResults of Observational StudiesNon-compliance

with OR practices◦ lack of proper OR

attire in sterile field◦ sterile technique

breeches◦ sterile field violations◦ inadequate site prep◦ questionable suture

technique

Physical restrictions◦ smaller rooms◦ multiple pieces of

equipment◦ traffic control issues◦ placement of red bag trash

Hematoma formation associated with increase risk of infection

References for References for RecommendationsRecommendations

HICPAC’s “Guidelines for Prevention of Surgical Site Infections, 1998”

AORN Standards, 1997APIC Text Infection Control and Applied

Epidemiology: Principles and Practice, 1996

Alexander’s Care of the Patient in Surgery

Special Procedures Area Special Procedures Area RadiologyRadiology

Cardiac Cath LabCardiac Cath Lab

InterventionsInterventionsEstablished training by surgeon for

medical staff in Cardiac Cath Lab and Special Procedure Area for Radiology◦Suture Technique◦Tissue handling techniques to reduce

risk of hematoma formation ◦Other OR recommended practices

InterventionsInterventionsAdopted/revised protocols for site prep

◦Larger area◦Appropriate use of skin antiseptics

Recommended the use of chlorhexidine gluconate (CHG)

Instituted Pre-operative showering with CHG

Provided feedback to staff on outcome after implementation of recommendations

InterventionsInterventionsOR personnel inserviced unit staff

◦Appropriate OR attire◦Sterile technique◦Instrument handling◦Traffic Control◦Room set up

Handling of red bag trash Covering cables Table set up

Key to Preventing Device Related Key to Preventing Device Related Infections Infections and Meeting Evolving Challenges and Meeting Evolving Challenges

Keep learningKeep monitoringKeep

implementing new patient safety infection control initiatives

Keep educating

BSIBSI

UTIUTI

VAVAPPALLALLHAI!HAI!